The brain drain debate: Community pharmacy and ARRS recruitment

As the Government hits its PCN recruitment target early, what effect has the movement of pharmacists had on the community sector? By Saša Janković 

The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to enable PCNs to create bespoke multi-disciplinary teams, funding 12 new roles including clinical pharmacists and pharmacy technicians.

The scheme’s aim was to support the recruitment of 26,000 additional staff into general practice by 2024, building and utilising these additional roles to solve the workforce shortage. However, earlier this year, the Government announced that it had already beaten this target, adding 29,103 additional staff into GP practices.

Data from NHSE published this May showed that since March 2019, there were 3.5 times more staff working in these roles in general practice – up from 11,500 in 2019 to over 40,600 as of March 2023. It also revealed almost two million more GP appointments delivered this March than a year ago, or 83,500 more appointments each working day.

The announcement that NHS England had hit its primary care recruitment targets early prompted an instant response from the community pharmacy sector. Company Chemists’ Association chief Malcolm Harrison said the recruitment of pharmacists via the ARRS must stop immediately.

Even the Government-commissioned review of Integrated Care Systems, published in April and authored by former Labour health secretary Patricia Hewitt, commented on the “unintended consequences” of recruiting community pharmacists into general practice.

In Hewitt’s summation: “The national requirements and funding of ARRS roles for community pharmacists within PCNs has, on occasion, exacerbated the problem of a general shortage of pharmacists, with some now preferring to work within primary care rather than remain in community pharmacies or acute hospitals, compounding the problem of community pharmacy closures and delayed discharges.”

Worryingly, in its report last year into integrating additional roles in PCNs, The King’s Fund found “a lack of shared understanding about the purpose or potential contribution of the roles, combined with an overall ambiguity about what multidisciplinary working would mean for GPs”. It said successful implementation of the scheme required “extensive cultural, organisational and leadership development skills that are not easily accessible to PCNs”. 

“These roles are one part of the pharmacy workforce and we now need to see a strategic approach to workforce planning across the system,” says Royal Pharmaceutical Society assembly member Thorrun Govind. “We know there are challenges when some pharmacists in ARRS roles are not adequately supported, and I look forward to NHS England addressing this variation in how to make best use of these roles.”

However, NHSE does not appear to be convinced that the evidence shows its policy has hollowed out the community pharmacy workforce. So does the real-world view fall somewhere in between?

One piece of the puzzle

Being president of the Primary Care Pharmacy Association (PCPA) and chief pharmacist and partner at Argyle Health Group in West London gives Graham Stretch a round view of the effect the recruitment of pharmacists to general practice and other primary care medical settings has had on community pharmacy.

“I accept that pharmacy professionals working in general practice have to come from somewhere,” he says. “But personally, almost all of my staff I train myself and I think this has to be the way forward. I would, however, argue that when you look much more closely at the numbers, ARRS has facilitated what was already happening and is only a small part of the story.”

Indeed, NHSE data shows there are 7,948 pharmacy professionals working in PCNs, of which 6,089 are pharmacists, but only just over 4,500 of these pharmacists are supported by ARRS.

“The big elephant in the room, of course, is how on earth we’re going to train all these people going forward, and how long it’s going to take to train them,” says Stretch. “For that, we need investment in training and a proper workforce plan.”

Adam Osprey, policy and development pharmacist at Community Pharmacy Scotland, is similarly vocal about the situation in Scotland.

“There are simply not enough pharmacist or pharmacy technician hours to satisfy the sharp spike in demand across Community, GP and Hospital services,” he says, calling the associated workforce planning “a reckless, short-sighted and siloed approach to solving a crisis in one area of the Health Service that has ultimately just shifted that crisis elsewhere”.

According to Osprey, while initial projections were for fewer than 200 pharmacists to be recruited, well in excess of 600 whole time equivalent posts have been created to date. “At a time when the output from the foundation year had been about enough to replace leavers, where we once had two strong pillars of pharmacy in community and hospital, we now have three that are crumbling under the pressure of not having adequate resource to realise their ambitions,” he says.

This has had a knock-on effect on community pharmacy businesses. “Despite adapting their offering in a number of ways to make community roles more attractive, our members are still reporting serious difficulty in securing people for permanent positions,” Osprey adds, “which has a real impact on the care provided to communities.” With this in mind, and since the Government has busted its own recruitment targets a year early, could now be the time to consider ending ARRS?

Janet Morrison, chief executive of Community Pharmacy England, says that while the movement of pharmacists into ARRS positions is “undoubtedly helping our general practice colleagues”, the impact on community pharmacy – where most of them have transferred from – “cannot be ignored”.

“With more than 6,000 pharmacists having been recruited into general practice, the scheme is exacerbating workforce problems by increasing vacancy rates and causing spiralling locum costs, which simply isn’t sustainable,” she says, adding that it “doesn’t appear that sufficient thought was given to the impact” it would have on the wider settings in which pharmacists work.

“We have heard that the hospital sector is also facing similar shortages of pharmacists,” she says, “so until we have a larger pharmacist workforce, their movement between settings will only solve one problem by creating another.”

As a result, Morrison says: “Yes, we still believe the ARRS policy should be stopped for the sake of saving community pharmacies, or the funding should be used to forge greater partnership working between GPs and community pharmacies. Meanwhile, we eagerly await the NHS long-term workforce plan, which must address the shortage of pharmacists across all settings, including community pharmacy.”

However, Stretch believes that stopping ARRS now would “in many ways, be throwing the baby out with the bath water”. He argues: “ARRS has delivered on the promise of the professional in patient-facing roles where they can truly, autonomously influence therapy and improve safety.

“I think to stop it now feels to me to be really short sighted, especially since we know that there are more people who have joined the [GPhC] register in that time than have potentially been lost.”

Stretch also points out that there have always been plenty of explanations for why people move jobs and change sectors. “The reason why people move is not money and generally they’re taking a pay cut [to go to a PCN role],” he says. “For example, the average wage for a new pharmacist in PCNs is £43,000, but Well has just announced it is going to pay new registrants £50,000. So why would you move for less money?”

Well, we know why, because the latest RPS annual wellbeing survey tells us the top factors causing poor mental health and wellbeing include inadequate staffing (70 per cent), lack of work/life balance (53 per cent), lack of protected learning time (48 per cent) and lack of colleague/senior support (47 per cent).

NHSE recently confirmed that PCNs will be able to increase ARRS salaries for pharmacists in line with the Government’s latest pay deal from 1 July, but without any funding uplift to do this. So even if their pay does increase, PCNs will have to find the money from within their own budgets, meaning recruitment for other areas may suffer.

Potential solutions to the standoff

While ARRS is an England-only scheme and does not apply in Scotland, Osprey says that a key action he would like to see in order to address workforce challenges is for undergraduate intakes and NHS Education for Scotland (NES) foundation year numbers to increase – “significantly and permanently”. However, he adds: “Clearly, this would take years to filter through, so in the short term, we need to be more creative.”

Strategically, Community Pharmacy Scotland has been hard at work establishing a funded post-registration foundation career pathway for employee pharmacists that includes independent prescriber (IP) training in partnership with NES and the schools of pharmacy.

“This supports newly qualified pharmacists to grow their confidence and competence without relying on them completing the qualification all in their own time,” Osprey says. “In the community pharmacy sector, we are seeing our members try new approaches to recruitment – offering a two-pharmacist model, looking at supporting portfolio careers and doing what is possible with working hours to improve work-life balance – for example, Monday to Friday work patterns.”

He says the establishment of advanced services such as Pharmacy First Plus, which utilises the IP qualification to support people with minor conditions, is also providing pharmacists with “a greater sense of professional satisfaction – so much so that we have already seen some movement back to community roles”.

Stretch thinks there is “absolutely a role for ARRS-funded pharmacists to work jointly between community and the GP network – as long as it takes into account that the most primary of primary care services is community pharmacy”.

He adds: “As the front door to the NHS with no appointments, there is no one else quite at the sharp end in the way that community pharmacy is. I think that’s got to be where we concentrate our efforts, rather than the whole divide and conquer thing, which I find upsetting.”

He is not alone in backing this strategy. Martin Bennett, managing director and superintendent pharmacist at Wicker Pharmacy in Sheffield, agrees that “sharing pharmacists and/or technicians, part of the week GP-based and part community pharmacy-based, provides opportunities to work cooperatively for the benefit of patients”.

Tony Schofield, superintendent pharmacist and owner of Flagg Court Pharmacy in South Shields, says: “As there seems to be no ‘winner’ in recruitment with all three sectors struggling to get sufficient pharmacists, job shares with sensible regulatory change (like remote supervision) sound sensible.”

Reasons for movement

But what of the ‘poached’ pharmacists themselves? Did a move out of community pharmacy bring the benefits they’d expected? 

Osama Madlom achieved IP annotation in 2017 and now works as a clinical pharmacist for Doncaster South PCN. “I was in the same branch for 18 years plus, and I wanted to use my IP,” he says. “It’s been a steep learning curve, but as an IP, I’m using my knowledge a lot more now and the upskilling has been immense. The pros are that you get a lot more professional fulfilment. The negatives are that primary care isn’t always an ideal environment for a pharmacist to be working in.” 

Natalie Prowse is PCN pharmacist at Torbay and South Devon NHS Foundation Trust, working for the GP surgeries within the Coastal Network PCN as an independent prescriber and pharmacy team lead. She moved from community to mainly primary care (GP surgery) more than three years ago and says she feels “generally more respected” as a professional. “I also use my skills and knowledge more,” she says, “and was more easily able to access the independent prescriber course. 

“I still work in community once a month and do enjoy it and seeing patients in person, but it is definitely more stressful.”

Laura Buckley also moved from community pharmacy to become a specialist clinical pharmacist in general practice in Yorkshire and lead for primary care at the Guild of Healthcare Pharmacists. She says the shift offered increased access to training and development opportunities, and she felt “much more integral” to the multidisciplinary team.

“Pharmacists in GP/PCN and community are mutually invaluable resources that exist to complement each other in stages of the patient journey,” she says. “The development of both roles can only serve to strengthen a profession that should be united in a common goal for ensuring medicines safety and excellent care provision.”